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The study was conducted in Pietermaritzburg within uMgungundlovu Health District. The main aim of the study was to explore the reasons why nurses fail to implement the available laid down procedures of dealing with adverse events. This was to be
achieved by firstly investigating the reasons for poor adverse events, secondly, by investigating whether the available reporting tools are being used, thirdly by identifying the nature of the current management system in place, fourthly by investigating whether the environment within which nurses operate is conducive to effective adverse events management, and lastly by investigating the quality of the existing management plan for dealing with adverse events. The quantitative research approach was used and the research instrument employed was a structured questionnaire comprising forty questions arranged in a Liekert Scale format. The
sample size was 213 participants out of a total population of 461.
The study found that as much as nurses are orientated on the policy of adverse events management, there is no ongoing training on the management of adverse events. Furthermore the study found that staff is not included in the planning on the
management of adverse events and the adverse events management committees are not fully representative of all categories of staff. The findings showed that there is lack of reporting on adverse events and further that the reporting tools are not primary
health care orientated. The findings further revealed that there is poor data and information management. The findings also revealed that as much as there is complains mechanism that is in place, the clinics fail to involve the community through the clinic committees on matters of adverse events management Findings also revealed a lack of supervision and oversight role. The staff
performance management is not aligned to managing adverse events. Another element is the fact that there is no improvement plan in plan following audits of quality care. The staff members are not even involved to discuss audit results. The study recommends that user-friendly tools that are relevant to primary health care activities be developed to ensure proper reporting. The study further recommends that adverse events should be incorporated in the nurse training programs, especially the Primary Health Care program as well as the in-service training programs. The study also recommends the training of the clinic managers to equip them with skills to be able to conduct monitoring and evaluation, coordination of programs and how to do strategic planning. The study further recommends that the staff performance management on adverse events be not limited to the focal person, but should be part of all healthcare workers. The study also recommends that the International Patient Safety day should be celebrated on a yearly basis and that this should be a key responsibility area of the district quality manager.